THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Protecting Your Privacy

I am required by law to maintain the privacy of your Protected Health Information (PHI) and to provide you with notice of my legal duties and privacy practices with respect to such information. This is an abbreviated copy; the full version is located in the lobby. You may request a copy at anytime.

The law permits the use or disclose of your health information without your written consent or authorization for the following purposes:

For Treatment, Payment, and Healthcare Operations

Treatment: I may use or disclose your personal health information to provide treatment services. For example, I may disclose your health information about you to other healthcare professionals involved in your care in order to coordinate services.

Health Care Operations: I may use or disclose your personal health information for some other business related matters that are called, in the law, Healthcare Operations. For example, to contact you, perform business audits, and to provide case management and care coordination.

Payment: I may use or disclose your personal health information to receive payment for your healthcare services. For example, I may use your information to send a bill for your healthcare services to you or to a collections agency.

As Required or Permitted By Law

Required by Law. I may use and disclose your health information when law requires that use or disclosure.

Victims of Abuse, Neglect, or Violence. I may disclose your information to a government authority authorized by law to receive reports of abuse, neglect, or violence.

Workers Compensation. Both state and federal law allow healthcare information that is reasonably related to a worker’s compensation injury to be disclosed without your authorization. These programs may provide benefits for work related injuries or illness.

Judicial and Administrative Proceedings. I may disclose your health information in the course of an administrative or judicial proceeding as required by a court order or as permitted in response to a subpoena.

Uses and Disclosures That Require Your Authorization

Except as described in this Notice or as permitted or required by law, I will not use or disclose your Protected Health Information without written authorization from you.

If you do authorize use or disclosure of your health information, you may revoke your authorization in writing at any time. If you revoke your authorization, I will no longer be able to use or disclose health information about you for the purpose covered by your written authorization. Your revocation will not apply to disclosures that I have already made with your permission.

Your Health Information Rights

You have the following rights under federal and state law with respect to your Protected Health Information:

Access. You have the right to inspect and obtain a copy of your Protected Health Information and billing records. You must submit a written request and a small fee of (.50/page) may be charged. You will receive a response from me within 15 days upon receiving your written request. Under certain circumstances, I may feel I must deny your request, but if I do I will give you a written explanation of the denial, which you can review.

Amendment. If you feel that there is an error or omission in your record, it is your right to request that it is corrected. The request must be made in writing and must include your reason to support the request. I will respond no later than 60 days from the date that the request was received. I may deny the request, in writing, if I find that the record is correct and complete, or if someone else provided the information.

Accounting of Disclosures. You have the right to request a list of disclosures for your records. I will provide a list of all disclosures except for those related to the following: coordination of treatment, billing, healthcare operations, or disclosures that you have requested. A small charge will incur if the request is more than a 12-month period.

Restrictions on Certain Users and Disclosures. You have the right to request a restriction or limitation on your PHI. I may not be legally bound to abide by all requests, but they will be reviewed. Agreed upon limits will be put in writing and respected. This does not include situations where disclosures are legally compelled. If you are paying out of pocket for your care, you have the right to not have any information released to insurance companies.

The Right to Request Confidential Communications. You have the right to request communication about treatment matters in a certain way, such as sending correspondence to an alternative address. To request confidential communication, you must make your request in writing. I will not ask you the reason for your request. I will accommodate all reasonable requests.

Changes to This Notice

This Notice of Privacy Practices is effective as of March 23, 2015, and I am required to abide by the Notice currently in effect. I reserve the right to change the terms of the Notice of Privacy Practice and to make the new Notice provisions effective for all Protected Health Information I obtain. This notice is located in the lobby and on my website. You may also request a written copy of a revised Notice of Privacy Practices.

Complaints

You have the right to file a written complaint with my office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this Notice or the policies and procedures of my office. Retaliation against those who file complaints is prohibited by law.

If you have any questions or want more information regarding this Notice, please contact: